Policies, Procedures and Forms for the UConn Health Center

Forms
The forms below are in Adobe Acrobat PDF format, and require the Acrobat Reader for viewing. If you don't have the reader, you can download it for free from Adobe. Resources designed to help people with visual disabilities access documents in the PDF format can be found at access.adobe.com.

Alien's Change of Address Card (AR-11)	80K PDF
Alien Data Collection Form	41K PDF
Authorization and Release	58K PDF
Candidate Selection Form	109K PDF
Classified Duties Questionnaire	187K PDF
CSEC	47K PDF
Designation of Retirement System-Tier-Plan-Beneficiary	35K PDF
Direct Deposit Authorization and Input Form	36K PDF
Domestic Partner Affidavit	155K PDF
Dual Employment Request	25K PDF
Employment Application	145K PDF
Employment Application for Faculty	75K PDF
Employment Eligibility Verification	181K PDF
Family Medical Leave Request	55K PDF
In-service Course Registration	6K PDF
Medical Certificate, Caregiver	66K PDF
Medical Certificate, Employee	72K PDF
Memorandum of Agreement	48K PDF
Name/Address Change	120K PDF
Payroll Check Pick-Up Authorization Form	64K PDF
Personnel Transaction Request	171K PDF
Reclassification Request Form	110K PDF
Search Request	778K PDF
Separation of Employment Clearance	27K PDF
Tuition/Conference Fee Reimbursement	201K PDF
Tuition Waiver Request for Dependent Children	109K PDF
Tuition Waiver Request for UHP Employees	112K PDF
UHP Position Information Questionnaire	147K PDF
Violent Incident Report	20K PDF
W-4 CT	47K PDF
W-4 Federal	237K PDF
W/C Filing Status and Exemption Form	147K PDF
W/C Mileage Worksheet for Medical Treatment	118K PDF
W/C Request for Use of Accrued Leave with W/C	89K PDF
W/C Third Party Liability Form - DAS	58K PDF
W/C Worker Status Report for Treating Physician	108K PDF
Workers' Compensation Hearings, Form 226	114K PDF
Worker's Compensation Medical Appointments, Form 226	25K PDF
Worker's Compensation Pharmacy Listing	99K PDF
Worker's Compensation Provider Directory	937K PDF